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Stasis dermatitis, a chronic varicose inflammation of the skin of the lower legs, frequently is complicated by the development of contact hypersensitivity. This retrospective study of forty-six patients with stasis dermatitis found a 60.9 percent incidence of at least one significantly positive patch test reaction. The two allergens that elicited positive reactions most commonly were neomycin and epoxy resin. These results and those of other authors reinforce our contention that patch testing should be a part of the routine work-up of patients with stasis dermatitis.

The life course of acrodermatitis enteropathica is recorded in a 62-year-old white man. Initially saved in infancy by breast-feeding and good medical care, later in his twenties he responded well to diiodohydroxyquinoline (Diodoquin) therapy, his only residua being dermatitis, hoarseness, and short stature. Subsequently untreated, this patient years later developed not only a dermatofibrosarcoma but also a large amelanotic malignant melanoma. Both were successfully excised. Subsequently, oral zinc therapy initiated for the first time cleared his acrodermatitis, which had been present for 60 years. It is suggested that this patient's malignancies developed as a result of an immune deficiency state typically found in acrodermatitis enteropathica. On this basis, acrodermatitis enteropathica may be viewed as having a malignant potential over the long term. The zinc-dependent nature of the immune deficit, however, suggests that lifelong daily zinc supplementation is an appropriate prophylactic measure.

A 36-yr-old patient suffering from chronic ulcerative colitis complicated by severe pyoderma gangrenosum of the leg is presented. Pyoderma gangrenosum rapidly progressed and failed to respond to a combined treatment of bed rest, prednisone, sulfasalazine, povidone-iodine, compresses, and debridement. Pyoderma gangrenosum responded and disappeared with no recurrence during the following months after the combined treatment of methylprednisolone, dapsone, and zinc sulfate.

Pretibial myxedema is considered an autoimmune complication or association of Graves' disease, Hashimoto's thyroiditis, and primary myxedema. The mechanism of lesion formation is unknown; the most plausible theory is that it arises as a result of a target cell in the skin, probably the fibroblast, being stimulated to produce abnormally high amounts of glycosoaminoglycans (especially hyaluronic acid) by autoantibodies directed against a thyroid antigen(s)--that is, by a cross reaction. One or more intermediary humoral agents may be involved in pathogenesis. The reason for the localization to the pretibial region is unknown; there is evidence that most patients with the disorder have similar abnormalities in the preradial skin. The condition may persist for months or years but often regresses spontaneously, accompanied by a parallel decline in, or disappearance of, serum anti-TSH-receptor autoantibody levels. Skin biopsies reveal evidence of increased amounts of hyaluronic acid and damage to collagen and elastic fibers. Local symptomatic treatment with corticosteroids is effective in most cases with slight to moderate severity of skin involvement. Repeated treatments are advised until such time that a spontaneous clinical remission occurs.

A case of extensive medical and functional morbidity in an elderly patient during treatment of pyoderma gangrenosum is described. Pyoderma gangrenosum is an uncommon cause of ulcerative skin lesions often involving areas of skin trauma about the lower extremity. Because of the possibility of underlying disease and the special treatment requirements, the condition must be differentiated from other, more common causes of skin ulceration. Treatment includes local care, systemic corticosteroid therapy, and control of any underlying disease. Pyoderma gangrenosum serves as a model for the interactions of various types of morbidity in the healthcare of the elderly.

A 27-year-old black man with Crohn's disease and nodules on the legs is described. Such nodules constitute one of three types of cutaneous manifestations which have a histological picture of a non-caseating granuloma. The two other varieties of skin lesions described are: that resulting from a direct spread from the gastrointestinal tract, and that resulting from spread over contiguous skin.

The incidence of contact allergy to 63 substances, including active principles and excipients used in a variety of topical preparations, has been studied by patch testing in 306 patients being treated conservatively for stasis dermatitis with or without ulceration. Positive reactions to one or more test compounds were recorded in 177 patients. The main offenders among drugs were neomycin, sulphonamide and promethazine; among the excipients, they were parabens, lanolins and benzoyl peroxide. Frequent reactions were observed to certain substances of the 'para' group, benzocaine, diaminodiphenylmethane, aniline and paraphenylendiamine, with the first three acting mainly as indicators of cross-sensitization. The extension and spread of allergic dermatitis can also be produced by drugs administered systematically. Recognition of the allergens responsible for allergic contact dermatitis arising at the lower leg site is a necessary condition if chronicity and spread of the dermatitis are to be prevented. For the same reason it is important to restrict topical applications to non-allergic substances.

The effect of prednisone treatment and plasmapheresis was studied in two patients with Graves' disease complicated by severe exophthalmos and/or pretibial myxedema. Titers of Thyrotropin Binding Inhibitory Immunoglobulins (TBII), Long Acting Thyroid Stimulator (LATS), antithyroid antibodies, and serum gammaglobulin concentrations, as well as clinical changes in exophthalmos and pretibial myxedema, were observed during the course of treatment. Steroid treatment lowered all of the abnormal antibody titers. Plasmapheresis did not change the TBII activity when determined using a fixed amount of immunoglobulin G fraction. However, serum gammaglobulin concentration was reduced by plasmapheresis, and therefore, total TBII activity in a unit of serum was reduced. Plasmapheresis also partially and temporarily resolved the pretibial myxedema, whereas no significant change in exophthalmos was observed. These results suggest that both steroid and plasmapheresis treatment are useful for lowering abnormal antibody titers in sera of patients with Graves' disease, and that plasmapheresis can be of some value in the treatment of pretibial myxedema.

The case is reported of a 64-year-old man in whom psoriasis developed in relation to Paget's disease of the underlying bone. Treatment of Paget's disease was associated with remission of psoriasis. We suggest that local hyperaemia is the common link in this association and that this lends support to the theory that vascular factors are important in the pathogenesis of psoriasis.

In 15 patients with venous or arterial insufficiency of the legs, bullous eruptions were observed on the lower legs. The bullae were subepidermally situated. Circulating antibodies against the basement membrane zone were not demonstrated in 2 cases investigated. This eruption seems to represent a clinical entity of unknown etiology.